RNSG 1105 Nursing Skills Final Exam -
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
RNSG 1105 Nursing Skills Final Exam
- All Modules 408 COMPLETE
DETAILED SOLUTIONS.
What interventions can be implemented to promote normal defecation? - ANSWER - Encourage fluid
intake of appropriate fluids, fruit juice, and water
- Encourage activity within patient's mobility regimen
- Instruct to eat more fruits and vegetables and have a bran cereal for breakfast
- Provide stimulant laxative and stool softeners as ordered
- Encourage to try to have bowel movement at the same time of day
What is an enema? - ANSWER An enema is a procedure in which a solution is administered into the
rectum and sigmoid colon to stimulate defecation
What is the primary reason for administering an enema? - ANSWER The primary reason for
administering an enema is to promote defecation by stimulating peristalsis
What are additional
reasons? - ANSWER 1.- Prevent involuntary escape of fecal material during surgical procedures and
childbirth
2.- Promote visualization of the bowel when an x-ray or exam is to be performed
3.- Bowel Training
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
,RNSG 1105 Nursing Skills Final Exam -
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
§ Tap water / Hypotonic - ANSWER Tap water/ Hypotonic- flow of a water is out of bowel into the
interstitial tissues which have higher pressure.
Action- distends intestine, increases peristalsis and softens stool before significant amounts of fluid are
reabsorbed
Adverse effects: Tap water enema should not be repeated more than 3x's because could cause water
toxicity, circulatory overload, fluid and electrolyte imbalance
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
§ Normal Saline - ANSWER Isotonic/ Normal Saline:
Equal concentration/ osmotic pressure on both sides of the membrane making it the safest type
Action: Distends intestine, increases peristalsis and softens stool
Adverse effects: fluid and electrolyte imbalance, sodium retention
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
§ Hypertonic solutions / Fleets - ANSWER Low Volume/ Hypertonic:
Hypertonic action- draws water out of the interstitial tissues into the colon which has a higher osmotic
pressure
Action: distends intestine, irritates intestinal mucosa to stimulate defecation reflex
Adverse effects: electrolyte abnormalities
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
,RNSG 1105 Nursing Skills Final Exam -
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
§ Soapsuds - ANSWER Soapsuds:
The soapsuds causes intestinal irritation to stimulate peristalsis
Use with caution in pregnant women and older adults because they could cause electrolyte imbalance
or damage to the intestinal mucosa
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
§ Oil retention - ANSWER Oil Retention:
These enemas lubricate the feces in the rectum and colon. the feces absorb the oil and become softer
and easier to pass
These enemas must remain in the colon for a prolonged period of time
Used mainly when the patient has an impaction
What PPE is appropriate to use when administering an enema? - ANSWER gloves and gown
What is the difference in the equipment used for a low volume enema
(prepackaged Fleets) and a high-volume enema? (9 items) - ANSWER Low volume:
Low volume enema bottle,
water soluble lubricant,
bedpan,
bedside commode or nearby bathroom ready for use with tissue paper,
water proof pad basin,
wash cloth,
towels and soap,
non-sterile gloves
, RNSG 1105 Nursing Skills Final Exam -
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
HIgh volume enema (10 items) - ANSWER High-volume:
Disposable enema set,
water soluble lubricant,
IV pole,
bedpan,
bedside commode, or nearby bathroom ready for use with tissue paper,
water proof pad basin wash cloth,
towels and soap,
and non-sterile gloves
What position is the patient placed for insertion of an enema? Why - ANSWER Position the patient on
the left side (Sims' position). This allows the enema solution to flow downward by gravity along natural
curve of sigmoid colon and rectum, improves retention of solution
Why is the tip of the enema tube lubricated? - ANSWER Lubrication provides for smooth insertion of
rectal tube without causing rectal irritation or trauma. With presence of hemorrhoids, extra lubricant
provides added comfort
How far should the enema tube be inserted into the rectum?
Which direction is the tube inserted in
the rectum? - ANSWER Insert the enema 3-4 inches for an adult. Direct it at an angle pointing toward
the umbilicus
How high is the enema bag placed above the mattress for a high-volume enema? - ANSWER 18 inches
above level of anus
What are common mixture for a large volume enema? - ANSWER Normal saline and glycerine
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
RNSG 1105 Nursing Skills Final Exam
- All Modules 408 COMPLETE
DETAILED SOLUTIONS.
What interventions can be implemented to promote normal defecation? - ANSWER - Encourage fluid
intake of appropriate fluids, fruit juice, and water
- Encourage activity within patient's mobility regimen
- Instruct to eat more fruits and vegetables and have a bran cereal for breakfast
- Provide stimulant laxative and stool softeners as ordered
- Encourage to try to have bowel movement at the same time of day
What is an enema? - ANSWER An enema is a procedure in which a solution is administered into the
rectum and sigmoid colon to stimulate defecation
What is the primary reason for administering an enema? - ANSWER The primary reason for
administering an enema is to promote defecation by stimulating peristalsis
What are additional
reasons? - ANSWER 1.- Prevent involuntary escape of fecal material during surgical procedures and
childbirth
2.- Promote visualization of the bowel when an x-ray or exam is to be performed
3.- Bowel Training
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
,RNSG 1105 Nursing Skills Final Exam -
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
§ Tap water / Hypotonic - ANSWER Tap water/ Hypotonic- flow of a water is out of bowel into the
interstitial tissues which have higher pressure.
Action- distends intestine, increases peristalsis and softens stool before significant amounts of fluid are
reabsorbed
Adverse effects: Tap water enema should not be repeated more than 3x's because could cause water
toxicity, circulatory overload, fluid and electrolyte imbalance
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
§ Normal Saline - ANSWER Isotonic/ Normal Saline:
Equal concentration/ osmotic pressure on both sides of the membrane making it the safest type
Action: Distends intestine, increases peristalsis and softens stool
Adverse effects: fluid and electrolyte imbalance, sodium retention
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
§ Hypertonic solutions / Fleets - ANSWER Low Volume/ Hypertonic:
Hypertonic action- draws water out of the interstitial tissues into the colon which has a higher osmotic
pressure
Action: distends intestine, irritates intestinal mucosa to stimulate defecation reflex
Adverse effects: electrolyte abnormalities
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
,RNSG 1105 Nursing Skills Final Exam -
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
§ Soapsuds - ANSWER Soapsuds:
The soapsuds causes intestinal irritation to stimulate peristalsis
Use with caution in pregnant women and older adults because they could cause electrolyte imbalance
or damage to the intestinal mucosa
What are the differences in the various types of cleansing enemas? How do they
help evacuate the bowel? What are contraindications?
§ Oil retention - ANSWER Oil Retention:
These enemas lubricate the feces in the rectum and colon. the feces absorb the oil and become softer
and easier to pass
These enemas must remain in the colon for a prolonged period of time
Used mainly when the patient has an impaction
What PPE is appropriate to use when administering an enema? - ANSWER gloves and gown
What is the difference in the equipment used for a low volume enema
(prepackaged Fleets) and a high-volume enema? (9 items) - ANSWER Low volume:
Low volume enema bottle,
water soluble lubricant,
bedpan,
bedside commode or nearby bathroom ready for use with tissue paper,
water proof pad basin,
wash cloth,
towels and soap,
non-sterile gloves
, RNSG 1105 Nursing Skills Final Exam -
All Modules 408 COMPLETE DETAILED
SOLUTIONS.
HIgh volume enema (10 items) - ANSWER High-volume:
Disposable enema set,
water soluble lubricant,
IV pole,
bedpan,
bedside commode, or nearby bathroom ready for use with tissue paper,
water proof pad basin wash cloth,
towels and soap,
and non-sterile gloves
What position is the patient placed for insertion of an enema? Why - ANSWER Position the patient on
the left side (Sims' position). This allows the enema solution to flow downward by gravity along natural
curve of sigmoid colon and rectum, improves retention of solution
Why is the tip of the enema tube lubricated? - ANSWER Lubrication provides for smooth insertion of
rectal tube without causing rectal irritation or trauma. With presence of hemorrhoids, extra lubricant
provides added comfort
How far should the enema tube be inserted into the rectum?
Which direction is the tube inserted in
the rectum? - ANSWER Insert the enema 3-4 inches for an adult. Direct it at an angle pointing toward
the umbilicus
How high is the enema bag placed above the mattress for a high-volume enema? - ANSWER 18 inches
above level of anus
What are common mixture for a large volume enema? - ANSWER Normal saline and glycerine
